Pyrex Journals 2035-7877

Pyrex Journal of Pharmacy and Pharmacology

Vol 1 (1) pp. 001-005 May, 2015
http://www.pyrexjournals.org/pjpp
Copyright © 2015 Pyrex Journals

Review Paper

Antidotes for Pesticide Poisoning: A Review

A Sharma*, PK Rai, D Raj, D Anghore, P Sharma

Laureate Institute of Pharmacy, Kathog, Tehsil Dehra, District Kangra, (H.P.) - India

th
Accepted 25 April, 2015

Pesticide poisoning kills hundreds of thousands of people in India each year. The majority are from deliberate self-
poisoning with Organophosphorus pesticides (OP), Aluminium phosphide and Paraquat. The current response from a
public health, medical and research perspective is inadequate. There are few proven or effective treatments; in addition,
very little clinical research has been done to transfer antidotes shown to work in animal studies into clinical practice. The
human toxicity of pesticides is poorly studied and better information might inform a more sustained and appropriate
regulatory response. Further understanding may also lead to improvement in diagnosis and treatment. The few effective
treatments are not being recommended or delivered in an optimal and timely fashion to poisoned patients. A regional
approach to facilitate appropriate pricing, packaging and delivery of antidotes is required.

Key words: Antidotes, Atropine, Pesticide, Organophosphorus, Poisoning, Paraquat.

INTRODUCTION

Self-poisoning with pesticides is a major problem. It is
estimated that hundreds of thousands of people die each year,
the majority from deliberate self-poisoning with
1
organophosphorus pesticides (OP) . Aluminium phosphide
and paraquat are also responsible for many deaths in some
areas. Although, the number of deaths indicates that this is a
major public health problem, of the same order of magnitude
as diabetes or HIV in many countries in the region, there is
little coordinated effort being applied to improve the medical
response to this problem. Only one antidote, atropine for OP
poisoning, could be regarded as being of proven effectiveness.
In this article we will describe further the requirements
antidotes need to meet in order to be useful in practice and our
experience with running clinical trials on pesticide antidotes in
India. We will then argue the case for more translational
research to progress antidotes that have been shown to be
effective in animals into human trials and the need for research
and planning for how best to provide and use these antidotes
in the resource poor rural areas of Asia where pesticide
2
poisoning is most important .
Pesticides, most frequently used in accidental/deliberate
intoxication globally; there is a scarcity of information on the
magnitude of both intentional and unintentional poisoning, as
well as on the relative importance of different pesticides. This
information is particularly lacking from most of Africa, and
detailed and accurate community-based data on the pesticides
responsible for fatal self-harm are not available for most of
rural Asia. Sentinel centers, that would need to be identified
and supported, could provide this information from across the
world. At any rate, it is known that the pesticides that cause
most deaths in rural Asia, and in the world, are WHO Class I
and II organophosphorus pesticides - causing an estimated
3
200,000 deaths .
At any rate, in rural Asia, the variety of pesticides
available in communities for intentional or unintentional
poisoning are large, reflecting the pesticides used in local
agriculture. Studies from Sri Lanka suggest that less than 20%
of pesticides used for self-harm 10 are bought for the purpose;
the majorities are freely available in the home or nearby
garden. The vast majority of these deaths are intentional;
unintentional oral or dermal exposure to WHO Class I OP
pesticides can cause severe poisoning, but the doses are
usually smaller than with intentional poisoning, resulting in
fewer deaths. WHO Class II OPs are generally less toxic in
unintentional poisoning. Where Class II OPs are the most
commonly used insecticides, unintentional poisoning is
generally less likely to cause severe poisoning. Class II OPs
are highly toxic in intentional overdose. Other classes of
pesticide that are common causes of significant and/or fatal
poisoning include carbamate and organochlorine insecticides,
the fumigant aluminium phosphide (a significant problem in
north India), and the herbicide paraquat. Less common causes
of significant poisoning include the herbicides chlorphenoxy
acetic acid derivatives and propanil, some pyrethroid
4
insecticides, avermectins, and amitraz . The locally available
pesticides will also determine how many poisoned people

Corresponding Author: choice.amit@gmail.com

Sharma et al
survive to hospital presentation. In areas where highly toxic,
fast acting WHO Class I organophosphorus (OP) pesticides
are used, the onset of poisoning can be so fast that many
people die before they can be taken to hospital. By contrast,
where slower acting pesticides are used, more patients will
survive to reach hospital and medical care. The case fatality for
different pesticides also varies markedly, from around 70% for
both aluminium phosphide and paraquat, to close to 0% for
5
many of the newer lower toxicity pesticides . Therefore,
hospital statistics, whether from primary or secondary
hospitals, must be interpreted in light of this difference. More
than half of global deaths from pesticide poisoning occur in
China, where currently, the WHO Class I OP pesticides are the
major problem, but where five Class I OPs (methamidophos,
methylparathion, parathion, monocrotophos, phoxim) have
been recently banned. This was expected to reduce the
number of poisoning deaths in China, and has since been
associated with a possible 10-15% fall in overall suicide rates
in women. In China, some deaths occur from pesticides that
are considered to be generally safe in poisoning. More recently
developed pesticides are generally safer than the older
pesticides still used widely in low- and middle income
countries. While the main international pesticide industry would
be keen to sell the newer pesticides, it is likely that the
generics and black market industry that is particularly active in
low- and middle income countries would not change their
6
sales .
Signs and Symptoms of Pesticide Poisoning: General
Pesticide poisoning can mimic the signs and symptoms of
other common diseases. It is important to find out exactly what
happened. Pesticide poisoning is likely only when a person is
known to have had recent exposure to pesticide. The person
may be wearing soaked clothing or known to have swallowed
pesticide, either accidentally or deliberately. All cases should
be seen by a doctor as soon as possible. It will be important for
the doctor to know the pesticide to which the person has been
exposed. If the container is available, send it to the poisoned
person for the doctor to see. Otherwise, copy the trade and
approved names of the pesticide from the label. The label may
include important notes on the treatment of poisoning, which
7
should be followed .
 Pesticide poisoning can affect the body in two ways: it
can cause a local reaction when a pesticide comes
into contact with exposed parts of the skin or eye, or it
can be absorbed into the body and cause a systemic
reaction. Local reactions vary from direct irritation
following a single contact to allergic reactions, usually
after multiple contacts with the same compound.
Pesticide poisoning is the appearance of systemic
8
reactions .
 Always check first if the poisoned person is breathing
and has a pulse. If necessary, start resuscitation
immediately, and do not waste time getting the
information above. However, someone else should be
asked to find the name of the pesticide, as it is
important that proper antidotes be used for some
9
types of pesticide poisoning .
www.pyrexjournals.org
PYRX. J. Pha.Pha | 002
Signs and Symptoms of Organophosphorous Poisoning
Poisoning by organophosphorous insecticides is the
commonest form of pesticide poisoning, and needs immediate
treatment.
ONSET: 1/2 - 24 hours after exposure
At first:
 The person feels sick
 Complains of headache
 General weakness or tiredness
Then:
 The person begins to sweat and salivate (water in the
mouth), may vomit and have diarrhea
 Complains of stomach cramps
 Pupils (of the eyes) become very small
 The person may mention blurred vision
 Muscles twitch, and hands shake
 Breathing becomes bubbly
 The person has a fit and becomes unconscious
Signs and Symptoms of Carbamate Poisoning
Carbamate insecticides have the same action as the
organophosphorous compounds, but they are much faster in
onset, and recovery is much faster. If a person is applying
these compounds and does not take the proper precautions,
symptoms will occur very quickly and work stoppage. Soon
after exposure ends, the person will start to feel better, unless
10
still absorbing pesticide from contaminated skin or clothing .
ONSET: Sometimes at work - 3 hours after exposure
At first:
 The person feels sick and may vomit
 Complains of headache and dizziness
 Tiredness and tightness in chest
Then:
 The person may begin to sweat and salivate
 May mention blurred vision
 Muscles may twitch
 Rarely, a person may have a fit and become
unconscious
The management of pesticide poisoned patients at various
levels of health care
In putting together the following elements of guidance for
health care workers at different levels of the health care
system, the experts who participated in the meeting considered
previously released guidelines, some of which were produced
by WHO, literature reviews, publications, and their extensive
experience and expert knowledge in this area. Basic elements
Respiratory failure is the primary cause of death following the
ingestion of pesticides, either due to specific anti-
cholinesterase effects of OP and carbamate poisoning, or - for
all pesticides - the non-specific complications of aspiration.
Also, much aspiration results from poor initial care of the
patient and/or unsafe gastric decontamination. Therefore, the
two basic elements of the clinical management of acute
intoxication with pesticides are airway management and
11
antidote administration .
The ABC of supportive care - Airway, Breathing, and
Circulation - is crucial. It is not possible to over-emphasize the
Sharma et al
need to apply the basic treatment correctly, to tailor treatment
to the patient, to evaluate the need for gastric decontamination,
and to give antidotes early. In emergency medical treatment
the initial management is pivotal, yet, in spite of a great
variation in initial management, with no standardization, the
basic principles of initial resuscitation and assessment are
often applied only after gastric decontamination for which there
is currently no evidence of benefit (American Academy of
Clinical Toxicology and European Association of Poison
12
Centre’s and Clinical Toxicologists, 2004 a, b .
Information on safe airway management and intubation
should be part of the basic training of any health worker and
included in any document on management of emergencies
published by health agencies and authorities. Gastric lavage
the importance of iatrogenic deaths as shown by the number of
deaths occurring after ingestion of low toxicity pesticides needs
to be emphasized13. The role of inappropriate gastric
decontamination in these deaths is important. There is a need
to tailor treatment to the poison and the patient; for example, if
a person has ingested a low toxicity pesticide 12 and does not
show clinical features of poisoning, it may be best to only
observe and support the patient rather than carrying out gastric
13
decontamination and giving antidotes .
There is much discussion about the use of gastric lavage
or forced emesis compared to activated charcoal in pesticide
poisoned patients. Recent studies indicate that single or
multiple doses of activated charcoal are safe in pesticide
poisoned patients, including patients receiving appropriate
amounts of atropine. By contrast, both forced emesis and
gastric lavage have potential serious complications if
performed in nonconsenting patients or unconscious patients
without airway protection However, in light of the absence of
direct data showing the benefits of charcoal over other forms of
gastric decontamination, it is difficult to make a strong
recommendation. Overall, if a patient presented within one
hour to a health care facility, the administration of activated
charcoal should be considered if the patient is conscious and
gives consent. The patient should not be forced to accept the
charcoal. Forced emesis is not recommended. Oral fluids
14
should not be given .
Pesticide poisoning and suggested therapies
Some common brand name chemicals containing
organophosphate compounds include Bidrin, Thimet, Orthene,
Dursban, and Guthion. Common chemical names for
organophosphate active ingredients include methyl parathion,
ethyl parathion, malathion, and chlorpyrifos. Organophosphate
insecticides affect people in much the same way they affect
insects -- the nervous system is damaged and breathing
becomes difficult. Symptoms of acute organophosphate
poisoning usually appear within 4 hours of the exposure.
Common, early symptoms may include headache, nausea, and
dizziness. The victim may also appear anxious and restless.
The later symptoms of a worsening condition are muscle
twitching, weakness, abdominal cramps, and vomiting.
Sweating, salivation, and tearing are often seen. Dark or
blurred vision and constricted pupils are other symptoms that
may occur. Tightness of the chest and coughing may lead to
respiratory depression, or the lungs may fill with fluid. Either
way, without immediate medical attention, the victim may die.
Two antidotes doctors use for treating organophosphate
poisonings are atropine and 2-PAM. Large doses of the
antidote may be needed for a severe poisoning, and follow-up
doses may need to be given for several hours to several
15
days .
www.pyrexjournals.org
PYRX. J. Pha.Pha | 003
Ingredients in LBAM butylated hydroxytoluene (World
Health Org)
Butylated hydroxyanisole (E 320) & Butylated hydroxytoulene
(E 321) are two antioxidants listed as possible cancerogenic
substances, according to WHO's cancer research tricaprylyl
methyl ammonium chloride, Potential Acute Health Effects:
(from MSDS data) Extremely hazardous in case of skin contact
(irritant), of eye contact (irritant), of ingestion, of inhalation
(lung irritant). Hazardous in case of skin contact (corrosive,
permeator). Inflammation of the eye is characterized by
redness, watering, and itching. Skin inflammation is
characterized by itching, scaling, reddening, or, occasionally,
blistering. polyvinyl alcohol: (MSDS data) Potential Acute
Health Effects: Slightly hazardous in case of skin contact
(irritant), of eye contact (irritant), of ingestion, of inhalation.
Sodium phosphate, immediate effects: Inhalation of this
product may be irritating to the nose and throat, causing
coughing and choking. Ingestion of large amounts may cause
diarrhea, nausea, vomiting and cramps. It may cause eye and
skin irritations. Potential health effects: Primary Routes of
entry: Inhalation, ingestion or skin absorption. Signs and
Symptoms of Overexposure: Dermatitis may develop from
repeated or prolonged skin contact. Eyes: Irritating. Skin:
Irritating. Ingestion: Nausea and vomiting. Inhalation: Irritates
the nose and throat and may cause coughing and chest
discomfort. Chronic Exposure: Dust may aggravate existing
pulmonary conditions and/or asthma. A Chemical Listed As
16
Carcinogen Or Potential Carcinogen .
Allopathic recommendations for pesticide poisoning
Skin decontamination is accomplished with a shower using
soap, large amounts of water, and shampoo. Skin folds, areas
underneath fingernails, ear canals, and other portions of the
body that may trap chemicals should be inspected and cleaned
carefully. Contact lenses should be removed, so the eyes can
be inspected and irrigated thoroughly if exposure is suspected.
Contaminated clothing should be removed, bagged, and
laundered carefully. Leather items usually cannot be
decontaminated and should be bagged and treated as
hazardous waste. – Gastric lavage Consider if the patient
presents within 60 minutes of ingestion. Insert orogastric tube.
Attempt aspiration first, followed by 100 to 200 ml normal
saline, then aspiration. Relatively contraindicated in
hydrocarbon ingestion it is indicated only when the potentially
life-threatening amount of poison is ingested and the
procedure can be done within 60 minutes of ingestion.
Cathartics used only in combination with activated charcoal
Sorbitol (1 to 2 ml/kg or 70 percent solution in adults, 1.5 to 2.5
ml/kg of 35 percent solution in children) Single dose only Not
recommended in poisonings that produce diarrhea
(organophosphates, carbamates, heavy metals in particular) or
those that produce ileus (paraquat and diquat) If it is used, it
should be as a single dose. Numerous contraindications:
absent bowel sounds, abdominal trauma or surgery, intestinal
perforation or obstruction, volume depletion, hypotension, or
17
ingestion of a corrosive substance .
First Aid Treatments
If the poison has been inhaled, as in the case of toxic
fumigants, the patient should be removed to the open air and
given artificial respiration. If the poison has been spilled on the
skin, it should be washed off immediately with large amounts of
Sharma et al
warm soapy water, scrubbing the skin thoroughly. Drop or
particles in the eyes should be removed by flushing with large
18
quantities of plain water .
If the poison has been swallowed, the stomach of the
affected person should be emptied as soon and as completely
as possible. After this has been done, a demulcent such as
raw eggs, milk or a thin flour paste can be given. These serve
to absorb the poison, and to soothe the irritated membranes. If
the specific poison is known, the following emergency
treatments could be given.
Acids
Limewater or milk of lime, milk of magnesia should be given,
arsenic Compounds. After emptying the stomach, raw eggs,
milk, lime water, flour, and water, or sweet oil should be given.
Benzene Hexachloride
Tea or coffee and gypsum salts may be given after the
stomach has been emptied. Chloroans, same treatment as
benzene hexachloride. The same treatment as for benzene
hexachloride
Mercury Compounds
Raw egg and milk should be given immediately.
Nicotines
After emptying the stomach, stimulants such as hot tea or
coffee should be given. Parathion after emptying the stomach
has a physician administer 1/30 to 1/60 grain of atropine
sulfate at hourly intervals, until pupils dilate.
Tetraethyl Pyrophosphate
The same treatment as recommended in the case of parathion
may be given. The following information will also be useful in
this connection.
IS: 4015 (Part I) 1967:
Provides information with regard to the first aid measures that
are necessary to be taken in cases of pesticide poisoning
before a physician attends the case.
IS: 4015 (Part II) 1967:
Outlines the basic information intended for the use of
physicians with regard to the symptoms, differential diagnosis
and treatment in relation to poisoning due to different types of
pesticides and their formulations during their use in a
laboratory, field or a factory.
Pesticide Disposal
There are a number of methods available to tackle the problem
of disposal of surplus pesticides, but they are not always
satisfactory for all types of materials. The methods, presently in
practice, include thermal decomposition, chemical
neutralization, burial and biological degradation.
www.pyrexjournals.org
PYRX. J. Pha.Pha | 004
Thermal Decomposition
This method requires exposure of the pesticide to a high
temperature (900-1000 °C) for varying periods of time. This
method is satisfactory enough as it degrades about 98% or
14
even more of most of the commercial pesticide formulations .
The exposure time should be sufficient so as to ensure
complete decompositions, and care must be taken to remove
air pollutants before the gases are discharged into the
atmosphere.
A wet scrubber and filtration through a porous clay bed
and carbon filter, with lagoon treatment of the waste water, are
suggested. Mercury, arsenic, lead and similar toxic compounds
should not be incinerated unless special residue handling and
disposal facilities are available.
Chemical Neutralization
This is feasible for most of the organophosphates and
carbonate insecticides, but not for the chlorinated
hydrocarbons. Various chemicals used to destroy the
pesticides are nitric acid, sulfuric acid, ammonium hydroxide,
sodium hydroxide, chlorine compounds, peroxides or other
types of active chemicals. Calcium hydrochloride seems to
have the broadest application. A strong acid or alkaline
19
hydrolysis does not provide complete treatment .
Burial
Burial is susceptible to contamination of waters and ground
waters from leaching and run off on pesticides. Careful shallow
burial with 18 inches of earth for small quantities of pesticides
in clay soil is generally acceptable until a better method is
developed.
The location should be well above ground water level,
downgrade, and several hundred feet from any source of water
supply and they should also be beyond the reach of children
and animals. The burial of pesticides in sandy soils is not
recommended as it has greater possibility of leaching into
20
surface water or ground water .
Biological or Natural Degradation
This method is satisfactory for short lived materials while for
other more persistent materials, the rate of degradation is too
slow. The persistence of some pesticides in soils is given in
proper facilities are available, surplus pesticides and
containers should be disposed of as described above.
Lead, Copper, Arsenic Dieldrin, BHC, DDT insecticides
Triazine herbicides Urea herbicides Benzoic acid herbicides 2,
4-D: 2, 4, 5-T Herbicides Organophosphorous insecticides
21-22
Carbamate (Carbaryl) insecticides .
Conclusion
As stated earlier, in spite of the short term advantages of
pesticides, they may create serious health hazards to human
beings in the long run. The fourth report of the Council of
Environmental Quality of the USA, published in 1972, has
virtually banned the use of DDT because this chemical, being
highly persistent, enters the food chain of innumerable forms of
life which results in a total dislocation of the balance of
13, 26
nature .
Unfortunately, the use of DDT is increasing in India, day
by day. Total consumption of pesticides per year is given in at
present, about 4000 tonnes of DDT are manufactured in India
Sharma et al
and an equal quantity is imported, mainly for malaria control.
Apparently the malaria carrying mosquito, Anopheles
culcifacious, has become resistant to many kinds of
18, 23
insecticides . 7.
The universe of cultivated crops often overlaps the
habitats of insects responsible for transmission of human
diseases. This is particularly true in the case of the mosquito
popu-lation, which breeds in diverse water bodies in all types
of situations. Repeated application of different pesticides
ensures exposure of genera of these insects of speedy
selection for resistance to the pesticides used. Increase in
malaria during the last few years has obviously made it
necessary to plan for a much greater use of DDT. Attempts are
being made to find alternatives to DDT like Methaxsichlor,
which, unlike DDT, is quickly degradable. An ideal pesticide is
Pyrethrum which is extracted from the flowers of a plant grown
widely in India. Pyrethrum is most effective, and being a
natural insecticide, is completely harmless to the environment.
Attempts are being made to grow Pyrethrum in Kashmir and
24, 25
Tamil Nadu, but, as yet, the output is very limited . 607.Eddleston M, Juszczak E, Buckley NA, Senarathna L, Mohamed
Biological control is, of course, the best way of dealing
with pests. This involves the use of bacteria, virus and other
pathogens which attack or by the use of predators or parasites
or both. A lot of work is yet to be done in this field, and
according to the Indian Council of Agricultural Research, there
has been considerable success in some fields. The most
suc-cessful of these was the almost total eradication of the
prickly pear, opuntia spp which had, like many toxic plants,
proliferated widely over the countryside in India, and was a
great menace for many years.
The Indian station of the Commonwealth Institute of
Biological Control situated in Bangalore is attempting to find
natural enemies of a number of pests, but this work is at a very
early stage. The extensive use of pesticides could have an
adverse effect on soil fertility and on crops.
The growing requirement for the use of pesticides is
obvious. But the harmful effects of pesticides with higher
persistence suggest the necessity for development of
25
pesticides which are biodegradable .
References
1. American Academy of Clinical Toxicology and European Association of
Poisons Centres and Clinical Toxicologists. Position paper: ipecac syrup(2004a).
Journal of Toxicology. Clinical Toxicology, 42: 133-143.
2. American Academy of Clinical Toxicology and European Association of
Poison Centres and Clinical Toxicologists. Position paper: gastric lavage(2004b).
Journal of Toxicology. Clinical Toxicology, 42: 933-943.
3. Buckley NA, Karalliedde L, Dawson A, Senanayake N, Eddleston M
(2004).Where is the evidence for the management of pesticide poisoning - is
clinical toxicology fiddling while the developing world burns? Journal of
Toxicology.Clinical Toxicology, 42: 113-116.
4. Davies JOJ, Eddleston M, Buckley NA (2008). Predicting outcome
inorganophosphorus poisoning with a poison severity score or Glasgow
ComaScale. Quarterly Journal of Medicine, 101: 371-379.
www.pyrexjournals.org
PYRX. J. Pha.Pha | 005
5. Dawson A, Buckley NA (2007). Integrating approaches to paraquat
poisoning.Ceylon Medical Journal, 52: 45-47.
6. Eddleston M (2000). Patterns and problems of deliberate self-poisoning in
the developing world. Quarterly Journal of Medicine, 93: 715-731.
Eddleston M, Buckley NA, Checketts H, Senarathna L, Mohamed F,
SheriffMHR, Dawson AH (2004). Speed of initial atropinisation in significant
organophosphorus pesticide poisoning - a systematic comparison of
recommended regimens. Journal of Toxicology. Clinical Toxicology, 42: 865-875.
8. Eddleston M, Eyer P, Worek F, Mohamed F, Senarathna L, von Meyer
L,Juszczak E, Hittarage A, Azhar S, Dissanayake W, Sheriff MHR, Szinicz
L,Dawson AH, Buckley NA (2005). Differences between organophosphorus
insecticides in human self-poisoning: a prospective cohort study. Lancet,
366:1452-1459.
9. Eddleston M, Karunaratne A, Weerakoon M, Kumarasinghe S,
Rajapakshe M,Sheriff MHR, Buckley NA, Gunnell D (2006a). Choice of poison
for intentional self-poisoning in rural Sri Lanka. Clinical Toxicology, 44: 283-286.
10. Eddleston M, Mohamed F, Davies JOJ, Eyer P, Worek F, Sheriff
MHR,Buckley NA (2006b). Respiratory failure in acute organophosphorus
pesticide self-poisoning. Quarterly Journal of Medicine, 99: 513-522.
11. Eddleston M, Haggalla S, Reginald K, Sudarshan K, Senthilkumaran
M,Karalliedde L, Ariaratnam A, Sheriff MHR, Warrell DA, Buckley NA (2007).The
hazards of gastric lavage for intentional self-poisoning in a resource poor
location. Clinical Toxicology, 45: 136-143.
12. Eddleston M, Buckley NA, Eyer P, Dawson AH (2008a). Medical
management of acute organophosphorus pesticide poisoning. Lancet, 371: 597-
F,Dissanayake W, Hittarage A, Azher S, Jeganathan K, Jayamanne S,
SheriffMHR, Warrell DA, for the Ox-Col Poisoning Study collaborators
(2008b).Multiple-dose activated charcoal in acute self-poisoning: a randomized
controlled trial. Lancet, 371: 579-586.
13. Green, M.A. 1987. An Outbreak of Watermelon-Borne Pesticide Toxicity.
American Journal of Public Health. Vol. 77 #4 November.
14. Freeman G, Epstein MA (1955). Therapeutic factors in survival after
lethalcholinesterase inhibition by phosphorus pesticides. New England Journal
ofMedicine, 253: 266-271.
15. Gunnell D, Fernando R, Hewagama M, Priyangika WDD, Konradsen F,
andEddleston M (2007a). The impact of pesticide regulations on suicide in
SriLanka. International Journal of Epidemiology, 36(6): 1235-1242.Gunnell D,
Eddleston M, Phillips MR, Konradsen F (2007b). The global distribution of fatal
pesticide self-poisoning: systematic review. BMC Public Health, 7: 357.
16. Johnson MK, Jacobsen D, Meredith TJ, Eyer P, Heath AJW, Ligtenstein
DA,Marrs TC, Szinicz L, Vale JA, Haines JA (2000). Evaluation of antidotes
forpoisoning by organophosphorus pesticides. Emergency Medicine, 12: 22-37.
17. Konradsen F, van der Hoek W, Gunnell D, Eddleston M (2005).
Missingdeaths from pesticide self-poisoning at the IFCS forum IV. Bulletin of
theWorld Health Organization, 83: 157-8.
18. Somasundaram k.v., Epidemiological profile of op poisoning cases
treatedat pravara hospital, loni, India, Indian J. Prev. Soc. Med. Vol. 40 No.3&
4,2009
19. Roberts DM, Seneviratne R, Mohamed F, Patel R, Abeysinghe M,
HittarageA, Buckley NA, Dawson AH, Eddleston M (2005). Deliberate self-
poisoningwith the chlorphenoxy herbicide 4-chloro-2-methylphenoxyacetic
acid(MCPA). Annals of Emergency Medicine, 46: 275-284. T
20. Tugwell P, Robinson V, Grimshaw J, and Santesso N (2006). Systematic
reviews and knowledge translation. Bulletin of the World Health
Organization,84(8): 643-651.
21. Handbook of Pesticide Toxicology, Volume 1, General Principles, W. J.
Hayes and E. R. Laws, Jr., eds. 1991. Academic Press. New York.
22. American Academy of Clinical Toxicology, European Association of
Poisons Centres and Clinical Toxicologists. Position statements. J Toxicol Clin
Toxicol. 1997; 35:699–709,711–19,721–41,743–52,753–62.
23. Reigart JR, Roberts JR. Recognition and management of pesticide
poisonings. 5th ed. U.S. Environmental Protection Agency, Washington, D.C.,
1999:11–6,34–8,40–5,48–53,55–62,64,68–9,76, 80–2,87–92.
24. Gallo MA, Lawryk NJ. Organic phosphorus pesticides. In: Hayes WJ,
Laws ER (eds). Handbook of pesticide toxicology. San Diego: Academic Press,
1991:938–41,951–2.
25. Members of various family practice departments develop articles for
“Practical Therapeutics.” This article is one in a series coordinated by the
Department of Family Medicine at the JSS University of Mysore.